MADISON, Wis.—Dr. Seth Foldy found himself dealing with a nationwide pandemic three months into the job as Wisconsin’s state health officer.

Six people in Wisconsin have died from swine flu and more than 6,000—more than any other state—have tested positive or are suspected of having it in the three months since.

Foldy, 53, led the state’s response to the flu outbreak and continues to work with local health officials on how to prepare for an even greater outbreak in the fall and coordinate distributing a vaccine that may not reach every person who wants it.

Foldy is no stranger to dealing with a public health crisis. In 2003, as health commissioner for the city of Milwaukee, he helped identify the first cases of monkeypox in the western hemisphere.

In an interview with The Associated Press last week, Foldy discussed lessons learned from the monkeypox outbreak that sickened 72 people in the Midwest, weaknesses in the state’s response to swine flu and the biggest health threat no one’s talking about.

AP: Wisconsin had the highest number of confirmed or probable cases of swine flu, and still does. You said before that’s because of “robust testing.” Was the aggressive and widespread testing for that in the state necessary or did those numbers unduly scare people?

Foldy: Was increased lab capability the only reason Wisconsin has so many confirmed cases? It appears it may not be the only reason. But an outbreak is like an iceberg. The part above the surface might be the people we can find and test. The part below the surface is everyone else. By having lots of testing capability it is quite clear we looked much further down the iceberg than many states were able to. …

Is it good to have this testing capability? The answer is yes. By having lots of lab-confirmed cases, we were able to assess how sick this virus was making people. We were able to look at a large number of tested cases and discover that very few people were getting seriously ill, or ill enough to be hospitalized or ill enough to die. If we did not have that lab capability, we would be less confident about how to categorize this outbreak as a killer. The information we created has been used by the nation and the world to assess how virulent or how harmful this particular strain is.

AP: In the face of the swine-flu outbreak, what have you seen as the biggest strengths and the biggest weaknesses in the state and local health departments’ ability to respond?

Foldy: There were many strengths, not the least of which is our awesome laboratory testing capabilities. Weaknesses fall in the area of first of all simply enough bodies on the ground to handle the huge influx of cases. … We never communicate as well or as much as we’d like. … But it is very difficult to get complex information into citizens, into residents of the state. Also, the job of shoveling very accurate technical information to clinicians, health care organizations, but also to schools and employers, was very stressful. …

It is always difficult to provide preventative and curative services in an outbreak when millions of Americans don’t have health insurance. And having to worry about creating separate systems for insured people and uninsured people is not only ridiculous and ethically questionable, it requires a national solution. We need a national health reform that will cover all Americans now. We needed it before flu; we need it twice as much with flu.

AP: How does not having that make it harder to combat a pandemic?

Foldy: Many people are able to get things like anti-viral medications through the routine health care system, but delivering that to people who have no method of paying for them ends up requiring the creation of parallel systems, which is the last thing we can afford to do when our backs are against the wall with too much work to do in general.

It confirmed our concerns that influenza from animals will inevitably break into the human population from time to time in a new form. And it confirmed this can be highly transmissible from person to person. We got off easy this time only because this virus turned out not to be too much more of a killer than routine seasonal influenza. If it killed with the efficiency of the 1918 virus, or the H5N1 avian flu virus, the consequences would have been disastrous. Because we’ve had a relatively mild season, we now have the opportunity to try to create a vaccine against this strain of influenza and we hope it will be ready in time to blunt the effect of the epidemic we expect to see in the fall.

AP: When do you expect to see the vaccine in Wisconsin?

Foldy: We hope to have a vaccine available for distribution sometime in the mid-fall, but it is unpredictable. It is possible it will be slow to be produced or not produced in the numbers we had hoped for.

AP: When you were in Milwaukee in 2003 you worked on identifying the first case of monkeypox in the western hemisphere. What did you learn from that public health crisis?

Foldy: We learned first that a communicable disease is always an emergency. This was our opportunity to make sure the monkeypox virus did not become a permanent feature in the western hemisphere. So being relaxed about that was not an option.

AP: Were there lessons learned from that experience that translated into the swine flu?

Foldy: Absolutely. Our after-action analysis of that event caused changes in the readiness structure and doctrine at both the local and state levels, although they are smaller and poorer. Nevertheless, because of planning and training and acquisition of specific tools, the average local health department in Wisconsin is many, many times better prepared for emergencies today than they were 10 years ago.

AP: What is the biggest public health threat that no one’s talking about?

Foldy: There are many candidates for that award. One answer that is relevant here is we are in the middle of a long-lived, unsuccessfully addressed epidemic of sexually transmitted diseases. It is a major cause of infertility, suffering, infant mortality. It has many different consequences, and we are frustrated for want of resources to attack that problem, reaching all the way up to the national level.

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